Case Report 1 (Anxiety due to another medical conditions)

Summary

A.A. was a 70 years-old woman, who came for treatment of skin infection (Eczema) at Allama
Iqbal Hospital. The presenting complaints of the client were itching, anxiety, worry, difficulty
sleeping, and unable to do work. The skin allergy of the client got worse due to diabetes and
turned into eczema which causes anxiety. The provisional formulation indicated diabetes as a
predisposing factor, while skin infection served as a precipitating factor. The perpetuating factor
was improper treatment. Support of family and the client’s strong insight about health were
protective factors. The client’s formal and informal assessment was based on behavioral
observation, clinical interview, DASS, BAI, and DSM5 TR Checklist. The results showed that
the client had a suspected problem of Anxiety Disorder due to Another Medical Condition. The
intervention/ management techniques used were Rapport Building, Psychoeducation, CBT, and
Relaxation Techniques.
Identifying Data

Name: A.A.

Husband’s Name: R.A.

Age: 70

Gender : Female

Education: 2nd Grade

Occupation Labour

Birth order 2nd

Religion: Islam

Assessment Date: January 09, 2024

Reasons and Source of Referral

The client was referred to the trainee clinical psychologist by Allama Iqbal Hospital for
the assessment and management of the client’s presenting problems like body itching, sleeping
problems, unable to do work, anxiety, stress, etc.
 ‫دورانیہ‬ ‫عالمات‬
‫دس ماہ سے‬ ‫جسم پر خارش ہوتی ہے‬
‫دس ماہ سے‬ ‫نیند نہیں آتی‬
‫دس ماہ سے‬ ‫بیٹھا نہیں جاتا‬
‫دس ماہ سے‬ ‫ہر وقت بے چینی رہتی ہے‬
‫دس ماہ سے‬ ‫گھر کے کام نہیں ہوتے‬
‫تین ماہ سے‬ ‫کبھی کبھار مرنے کا دل کرتا ہے‬
‫سات ماہ سے‬ ‫طبیعت کی وجہ سے پریشان رہتی ہوں‬
Presenting Complaints

Presenting Complaints and Duration of Client’s problems according to Psychologist

Initial Observation

The client was observed in OPD. Within the session, the sitting posture of client was not
right and seemed a little bit restless because of her medical conditions (eczema). The eye-contact
of the client was appropriate. The voice tone of the client was not good as her voice was
trembling. Throughout the session, the client continuously shake her legs and head. The overall
appearance of the client was appropriate. The client was also observed out of the session. She
was anxious and uneasy due to her medical condition.

Developmental History of the Problem/ History of Present Illness

The client was suffering from diabetes for almost seven years but the main problem
started when her grand-daughter was born. At birth, her grand-daughter had a bacterial infection
on her body due to poor hygiene of mother during pregnancy. Because of this infection, then
client and her whole family got the same infection on their bodies. It was started almost ten
months ago but it got worse for client due to diabetes and turned into eczema. At start (before 10
months), the client consulted doctor and took medicines continuously for one month and it got
better but after few months due to change of weather (winter season), it got triggered and spread
all over her body. Now her skin was extremely itchy and had red spot all over it.
Background Information

Personal History

The client was seventy years old woman. She belonged to a middle-class family. Her
house was not full of luxuries and comforts of life but she was never neglected by her family.
She spend a lot of time with his family and loved to play with her grand-children. She liked to
offer prayers and recite Quran and was a spiritual woman. She also loved to help others or to
fulfil other’s needs.

Premorbid History

Before the onset of client’s problems, the client lived a peaceful life. She used to spend a
lot of time in kitchen to prepare food for her children by herself and spend her free time with her
grand-children. She also had a calm sleep and enjoyed afternoon naps. All these were affected
since the onset of the client’s problem.

Family History

The client was lived in a joint family system and had middle socio-economic status. The
client was living with her husband and one married and one unmarried son. The authoritative
member of the family was her husband. He was educated up to primary level and worked in a
factory. He had satisfactory relations with the client. The client had six children, four sons and
two daughters. Two daughters and three sons are happily married and the younger son was
studying yet. All the children love her. They pay attention to her and show concern about his
problems. Regarding religious inclinations, all the family members had firm religious beliefs and
were practical about them.

Educational History

The client had education up to elementary level only (till 2nd grade). After that she quit
schooling and started Islamic Education. She had good relationships with her teachers and class
fellows and her favourite subject was Urdu. The client’s school performance was satisfactory.

Social History
 The client spends most of her time with her family members and grand-children. She also
had friends in neighbourhood and loved to hang out with them. The client was socially active.
She was caring, friendly and liked to help others.

Sexual History

The client reached the age of puberty at age 14. Her reaction to bodily changes was
normal and she did not face any complications in this regard.

Occupational History

The client was a housewife and loved to do household chores.

History of Psychiatry/ Medical Illness

The client had family history of hypertension and diabetes and was suffering from it for
almost seven years. She was also suffering from stress due to her husband’s accident and his after
condition. But she recovered from it as her husband’s health got better.

Drug History

The client was taking medicines for hypertension and diabetes for many years but she
never took any addictive drug.

Marital History

The client had arrange marriage and was living a satisfactory married life. Both (husband
and wife) were loyal to each other. The client had six children (two daughters and four sons). All
of them share a strong bond with her. The overall home environment of the client was good.

Provisional Formulation

On the basis of above history, the client might be suffering from Anxiety Disorder due to
another medical conditions (eczema and diabetes) as evident from the history of present illness
that the skin infection got worse due to diabetes and turned into eczema, which affect client’s
normal life functioning.

Assessment

Informal Assessment
 This type of clinical assessment involves a flexible style of assessment such as semi-
structured or non-structured interviews (with no or less predetermined format) or observation
(verbal, non-verbal, and hygienic factors). Informal assessment in clinical psychology means that
gathering the data informally by observing the client and by Interview in which the questions are
asked of the client and the client’s family. From informal assessment, the behaviour of the client
and from the interview along with Mini Mental Status Examination (MMSE).

Behavioral Observation. It is method used to observe, describe and explain the

behaviour when it’s naturally occurred in some real-world setting (Juomakish, 1994). Behavioral
Observation is a systematic way of recording the observable responses of behavior (Pillaring,
2014). The rationale behind that is to assess the client’s problems, explore the presenting
complaints of the client so that management and goals could be planned. Behavioral observation
was done to assess the client’s interest, abilities and appearance. The client was observed in
session. The client’s hygiene was appropriate; seat behavior and eye contact were also
appropriate. The voice tone of the client was not good as her voice was trembling. Throughout
the session, the client continuously shake her legs and head. The overall appearance of the client
was appropriate.

Clinical Interview. It is a way of gathering information, ask questions and engaged in

dialogues to learn more about the client and form initial opinions about a client psychological
state (Milterenberger, 1997). Clinical Interview is a main tool of gathering information from
client, parents, and other informants (Reynolds, 2014). It involves setting treatment goals and
ensuring confidentiality while tailoring interventions to meet individual needs. The rational of
this interview is that gathering information about the client’s behavior. The interview revealed
that the client has difficulty in sleep body itching, sleeping problems, unable to do word, anxiety,
and stress. Contacted the client’s daughter-in-law, she reported about the same problems.

Subjective Rating Scale. Rating the client symptoms as reported by client and trainee
clinical psychologist.

Table 2
Client’s Symptoms Pre-assessment Rating Scale (0-10)
Symptoms Rating by Therapist (0-10) Rating by Client (0-10)
 Anxiety 6 9
Difficulty to Sleep 6 8
Unable to do Work 7 9

Formal Assessment

Formal assessment is used in psychology combines a process of interviewing a subject or

client and using appropriate test instruments and written assessments to identify the issues
involved in the case and to arrive at an appropriate diagnosis. Through formal assessment
information is collected about the client in a formal way by using testing tools, scales, or
measuring screening tools according to APA to measure the severity level or severity index of the
disorder.

DSM V-TR Checklist. According to the diagnostic criteria of DSM-5- TR, according to
symptoms the client might be suspected of Anxiety Disorder due to another Medical Condition.

DASS. This test is a quantitative measure of distress in an individual along with the three
axes of depression anxiety and stress during the past week. It has 21 items (Lovibond, 1995).
The cut-off scores for depression ranges from 5-6, for anxiety ranges from 4-5, and for stress
ranges from 10-12.

Quantitative Interpretation. The quantitative interpretation of this scale is as follow.

Depression Anxiety Stress

Normal 0-4 0-3 0-7
Mild 5-6 4-5 8-9
Moderate 7-10 6-7 10-12
Severe 11-13 8-9 13-16
Extremely Severe 14+ 10+ 17+

Qualitative Interpretation. The client’s score for depression, anxiety and stress are 5, 17
and 10 respectively. It means that the client is suffering from mild depression, moderate stress
and extremely severe anxiety.
 Beck Anxiety Inventory. This test is to measure the level of an individual’s anxiety. It is
a 21-items self-report inventory that is used to measure the individual’s anxiety during the past
month (beck, 1993). The cut-off score of the Beck Anxiety Inventory ranges from 22-35.

Quantitative Interpretation. The quantitative interpretation of this scale is as follow.

Low Moderate Severe

Anxiety 0-21 22-35 36+

Qualitative Interpretation. The client’s score for anxiety is 41. It means that the client is
suffering from extremely severe anxiety.

Case Formulation

The case formulation was done after the assessment, according to the Bio-Psycho-Social
Model in which included factors were predisposing, precipitating, perpetuating and protective.

Predisposing factors are those that put an individual at risk of developing a problem.
These may include genetics, life events, or temperament (Racin et al., 2016). According to the
given history, the client’s predisposing factor was diabetes which is a genetic disease in client’s
case. Health conditions that are genetic and associated with high levels discomfort or pain may
put people at greater risk of future anxiety (Gabalawy et al., 2014).

Precipitating factors refer to a specific event or trigger to the onset of the current problem
(Racin et al., 2016). The severe skin allergy which turned into eczema was the precipitating
factor of the client. Intense itching significantly reduces the quality of life, and is associated with
psychiatric conditions, such as anxiety and depression (Iida et al., 2023).

Perpetuating factors also known as maintaining factors are those that maintain the
problem once it has become established (Racin et al., 2016). The factors that maintain the client’s
problem are improper treatment and old age. Being a female increases the likelihood of being
anxious in the general population and people with diabetes (Khuwaja et al., 2010).

The protective factors are the strengths of the individual or reduce the severity of
problems and promote healthy and adaptive functioning (Racin et al., 2016). The protective
factor involved good insight into her health and family support. A good perception of the disease
depends on its severity and strong feelings of a good outcome (Al-Khathami et al., 2017).

Case Conceptualization
Presenting Complaints

• Anxiety
• Sleepiness
• Inability to do work
• Worry
• Agitation
• Restlessness

Assessment
Informal Assessment
• Behavioral Observation
• Clinical Interview
• Subjective Rating Scale
Formal Assessment
• DSM -5TR Checklist
• DASS
• BAI

Precipitating Factors Perpetuating Factors

Predisposing Factors
• Skin Allergy • Improper Treatment
• Diabetes
(Eczema) • Old Age
\
\
\
\
\
\
\
\
\
\
\

Protective Factors

• Family Support
• Client’s Insight
 Proposed Management Plan

• Rapport Building
• Psychoeducation
• Relaxation Technique
Diagnosis • Cognitive Behavioral Therapy

According to DSM-V-TR client falling under the criteria or might be fulfilling the
symptoms of anxiety disorder due to another medical condition (Eczema) F06.4, Severe level.

Client’s Prognosis

In the client’s case, the prognosis or chances of recovery were high but it can be
influenced by various factors, some of which are favourable, while others are unfavourable.

Favorable Factors

• Social Support including her husband's and children’s support

• Strong insight into her health can be the strong favorable point

• Proper treatment and take care of herself

• Strong spiritual beliefs can take her to recovery

• Strong socialization with her neighbors and friends can cause positive impacts

Unfavourable Factors

• If the treatment is still discontinued this time, causes the condition to get worse
• Old age is more prone to diseases and may cause severity of the problem

Intervention Strategies

Short term Goals

• To Establish a strong therapeutic relationship with the child

• To manage stress
 • Encourage her to take part in hobbies gradually
• Help the client to improve her sleeping schedule
• Establish a trusting and comfortable therapeutic relationship with the child to encourage
open communication
• Teach relaxation techniques and coping strategies to help the child manage anxiety
• Educate the client about anxiety, and the effects of these conditions, providing him with
tools and knowledge to address these challenges

Long term Goals

• Continuation of short-term goals.

• Change the client’s negative thoughts to positive ones
• Proper follow-up sessions with the client
• To follow complete treatment plan
• Collaborate with the client’s family to increase their understanding of anxiety, ensuring
they provide necessary support

Proposed Management plan

A proposed management plan designed to help the client to help her with her
psychological well-being and support. Rapport Building and Psychoeducation are the key
factors at initial point steps of management plan.

Rapport building

Rapport refers to a harmonious relationship between the patient and the healthcare
profession which is based on cooperation and respect. A good rapport with the client is said to
improve the patient’s therapeutic results, happiness, satisfaction, and compliance with treatment
(Butt,2021). The client was expressive about her thoughts and feelings. Overall, proper sessions
were conducted and the client was responsive to each question asked in clinical interview and
built a good professional bond with trainee clinical psychologist.

Psychoeducation
 Psychoeducation is an intervention involves interaction between the information provider
and the mentally ill person or his/her caregiver (Lincoln & Wilhelm, 2007). Psychoeducation
would help the client to show compliant behavior regarding the treatment of any psychological
issue. Psychoeducation could provide awareness to the client regarding her issue and which
practices can help in overcoming those issues and problems. Overall, the client and her daughter-
in-law was psycho-educated about her condition its psychological impacts on client’s life.

Cognitive Behavioral Therapy

Cognitive behavioral therapy combines both cognitive and behavioral therapies to deal
with the current problems of the client. CBT is a directive form of psychotherapy that assists
patients in questioning their troubling ideas and altering the behaviors that are connected to them
(Beck, 1960). CBT was used with the client to help her realize her feelings and thoughts which
can be harmful and how we can modify them, and made us positive and in a happy mood and can
help in recover her skin disease soon.

Relaxation Techniques
The use of therapeutic relaxation techniques has been developed to benefit people by
lowering stress and anxiety Guided imagery, progressive muscle relaxation, deep breathing, and
other techniques for relaxation are some of them (Norelli et al., 2022). To treat stress, anxiety,
sadness, and pain, these techniques could be expanded to include a variety of contexts. The client
was taught Deep breathing and guided imagery to manage stress and anxiety.
Limitations
• Unavailability of a psychiatric ward
• Time to gather information was very limited as proper time was not given for gathering
more data.
• The session was not much comfortable while the sessions due to the presence of other
patients.
Recommendations
• There should be a proper psychiatric ward
• Time period for assessment should be extended.
• Information should be gathered from significant others.
 • Assessment should be carried out in an open environment which should be free of
distractions.

Session Report

Session 2 14-01-2024

The session was carried out in the OPD of the Allama Iqbal Hospital. The client was
assessed both formally and informally. The client’s history was taken through a clinical interview
during which the client was observed for her verbal and non-verbal behaviour. According to the
presenting complaints of the client, Beck's anxiety inventory and Depression Anxiety Stress
Scale was also administered for a better evaluation of the client’s reported symptoms. The
session ended with an assessment of the client’s condition. The session was ended after rapport
building and psycho-educating the client about her condition and telling her ways to improve her
psychological wellbeing. The overall session was ended on a good note.
Case Report 2 (Generalized Anxiety Disorder with Comorbid Persistent Depressive Disorder)
 Summary

A.A. was a 50 years-old woman, who came for treatment of spinal pain at Allama Iqbal
Hospital. The presenting complaints of the client were anxiety, worry, unable to do work,
tension, insomnia, loneliness, severe headache, stress. The brain injury of the client got worse
due to low socio-economic status and improper treatment. The provisional formulation indicated
poverty and divorce as a predisposing factor, while separation from children and conflicting
second marriage served as a precipitating factor. The perpetuating factor was improper treatment.
Client’s strong insight about health were protective factors. The client’s formal and informal
assessment was based on behavioural observation, clinical interview, DASS, BDI, GAD-7 and
DSM 5 TR Checklist. The results showed that the client had a suspected problem of generalized
anxiety disorder with comorbid persistent depression disorder. The intervention/ management
techniques used were Rapport Building, Psychoeducation, CBT, and Relaxation Techniques.
Identifying Data

Name: A.A.

Husband’s Name: A.Q.

Age: 50

Gender : Female

Education: Primary Level

Religion: Islam

Assessment Date: January 13, 2024

Reasons and Source of Referral

The client was referred to the trainee clinical psychologist by Allama Iqbal Hospital for
the assessment and management of the client’s presenting problems like tension, insomnia,
unable to do work, anxiety, severe headache, stress and suicidal ideation.
Presenting Complaints
Presenting Complaints and Duration of Client’s problems according to Psychologist
‫دورانیہ‬ ‫عالمات‬
‫پندرہ سال سے‬ ‫ہر وقت پریشانی رہتی ہے‬
‫پندرہ سال سے‬ ‫لگتا ہے کچھ برا ہونے واال ہے‬
‫بارہ سال سے‬ ‫نیند نہیں آتی‬
‫پندرہ سال سے‬ ‫دل کی دھڑکن تیز رہتی ہے‬
‫ڈیڑھ سال سے‬ ‫دماغ میں درد رہتا ہے‬
‫بیس سال سے‬ ‫تنہائی کا شکار رہتی ہوں‬
‫دو سال سے‬ ‫کوئی میری پرواہ نہیں کرتا‬
‫چھ سال سے‬ ‫مرنے کا دل کرتا ہے‬

Initial Observation

The client was observed in OPD. Within the session, the sitting posture of client was right
but seemed a little bit restless because of her medical conditions. The eye-contact of the client
was appropriate. The voice tone of the client was not good as her voice was trembling.
Throughout the session, the client continuously shook her legs and head. The overall appearance
of the client was not appropriate as her hygiene was poor. The client was also observed out of the
session. She was anxious and uneasy due to her medical condition.

Developmental History of the Problem/ History of Present Illness

The client was suffering from head and spinal pain for almost eighteen months but the
main problem was poor socio-economic status. The client was divorced twenty-five years ago
and separated from her children. After second marriage, the economic conditions got worse and
unsatisfactory relationship with spouse results in heart attack for almost eleven years ago. After
brain injury (before 10 months), the client consulted doctor and took medicines continuously for
one month and it got better, it got worse. So, the poor socio-economic status and improper
treatment of brain injury had psychological impacts on the client’s life.

Background Information

Personal History

The client was fifty years old woman. She belonged to a low-class family. Her house was
not full of luxuries and comforts of life and she was neglected by her family. She spends a lot of
time on overthinking about her financial conditions as she hardly had food to eat and worry
about how to pay debts. Besides this, she liked to offer prayers and recite Quran.

Premorbid History

Before the onset of client’s problems, the client’s life was not peaceful. She used to spend
a lot of time in quarrel with her first husband for money. She spend his most of life in poverty.
The only difference is that, she had her mother and brother’s support before the onset of
problem.

Family History

The client was lived in a nuclear family system and had middle low-economic status. The
client was living with her husband. The authoritative member of the family was her husband. He
was not educated and was a driver. He had no satisfactory relations with the client. They both
quarrel with each other every time due to financial conditions. The client had six children, four
daughters and two sons. One daughter and one son are from first marriage and are married but
the client had no contact with them as they were with their father. From second marriage, the
client had four children (Three daughters and one son). The elder daughter was died at the age of
eighteen months due to heart issue and the son was died during delivery. The remaining two
daughters were married and they both did not have satisfactory relations with their in-laws, nor
they care for the client. They both are busy in their lives. Regarding religious inclinations, all the
family members expect client not had firm religious beliefs and were not practical about them.
Educational History

The client had education up to primary level only. After that she quit schooling. She was
not a brilliant student. She did not had good relationships with her teachers and class fellows and
her favourite subject was Urdu.

Social History

The client spends most of her time on over-thinking. She had nobody with whom she can
share her feelings and emotions. She preferred to be alone and did not like to hang up with
others. The client was not socially active.

Sexual History

The client reached the age of puberty at age 13. Her reaction to bodily changes was
normal and she did not face any complications in this regard.

Occupational History

The client was a housewife and loved to do household chores.

History of Psychiatry/ Medical Illness

The client had family history of hypertension and was suffering from it for almost thirty
years. She was also suffering from stress due to her financial condition.

Drug History

The client was taking medicines for hypertension and brain and spinal cord injury for
many years but she never took any addictive drug.

Marital History

The client had arranged marriage and was living a unsatisfactory married life. Both
(husband and wife) quarrel with each other. The client had six children (four daughters and two
sons). All of them did not share a strong bond with her. The overall home environment of the
client was not good.
Provisional Formulation

On the basis of above history, the client might be suffering from Generalized Anxiety
Disorder as evident from the history of present illness that she had fear that everything bad will
happen to me with comorbid Persistent Depressive Disorder as evident from the history of
present illness that she felt loneliness and wanted to die.

Assessment

Informal Assessment

This type of clinical assessment involves a flexible style of assessment such as semi-
structured or non-structured interviews (with no or less predetermined format) or observation
(verbal, non-verbal, and hygienic factors). Informal assessment in clinical psychology means that
gathering the data informally by observing the client and by Interview in which the questions are
asked of the client and the client’s family. From informal assessment, the behaviour of the client
and from the interview along with Mini Mental Status Examination (MMSE).

Behavioural Observation. It is method used to observe, describe and explain the

behaviour when it’s naturally occurred in some real-world setting (Juomakish, 1994). Behavioral
Observation is a systematic way of recording the observable responses of behaviour (Pillaring,
2014). The rationale behind that is to assess the client’s problems, explore the presenting
complaints of the client so that management and goals could be planned. Behavioural
observation was done to assess the client’s interest, abilities and appearance. The client was
observed in session. The client’s hygiene was not appropriate; seat behaviour and eye contact
were also appropriate. The voice tone of the client was not good as her voice was trembling.
Throughout the session, the client continuously shook her legs and head. The overall appearance
of the client was inappropriate as her hygiene was poor.

Clinical Interview. It is a way of gathering information, ask questions and engaged in

dialogues to learn more about the client and form initial opinions about a client psychological
state (Milterenberger, 1997). Clinical Interview is a main tool of gathering information from
client, parents, and other informants (Reynolds, 2014). It involves setting treatment goals and
ensuring confidentiality while tailoring interventions to meet individual needs. The rational of
this interview is that gathering information about the client’s behaviour. The interview revealed
that the client has tension, insomnia, unable to do work, anxiety, severe headache, stress and
suicidal ideation.

Mental Status Examination (MSE). An organized evaluation of the patient’s cognitive

and behavioural abilities is called a mental status examination. The features and overall conduct
of the patient, their degree of awareness and focus, their motor and verbal functions, their
emotional state, their perception and thought processes, their attitude and insight, the response
the examiner elicited, and, lastly, their higher cognitive abilities are all addressed (Martin, 1990).

Subjective Rating Scale. Rating the client symptoms as reported by client and trainee
clinical psychologist.

Table 2
Client’s Symptoms Pre-assessment Rating Scale (0-10)
Symptoms Rating by Therapist (0-10) Rating by Client (0-10)
Anxiety 9 9
Difficulty to Sleep 8 8
Unable to do Work 7 9
Loneliness 8 9
Extreme Worry 8 9

Formal Assessment

Formal assessment is used in psychology combines a process of interviewing a subject or

client and using appropriate test instruments and written assessments to identify the issues
involved in the case and to arrive at an appropriate diagnosis. Through formal assessment
information is collected about the client in a formal way by using testing tools, scales, or
measuring screening tools according to APA to measure the severity level or severity index of the
disorder.

DSM V-TR Checklist. According to the diagnostic criteria of DSM-5- TR, according to
symptoms the client might be suspected of Generalized Anxiety Disorder with comorbid
Persistent Depressive Disorder.
 DASS. This test is a quantitative measure of distress in an individual along with the three
axes of depression anxiety and stress during the past week. It has 21 items (Lovibond, 1995).
The cut-off scores for depression ranges from 5-6, for anxiety ranges from 4-5, and for stress
ranges from 10-12.

Quantitative Interpretation. The quantitative interpretation of this scale is as follow.

Depression Anxiety Stress
DASS 14+ 10+ 0-7

Qualitative Interpretation. The client’s score for depression, anxiety and stress are 21, 17
and 7 respectively. It means that the client is suffering from extremely severe depression,
extremely severe anxiety and mild stress.

Beck Depression Inventory. This test is to measure the level of an individual’s

depression. It is a 21-items self-report inventory that is used to measure the individual’s anxiety
during the past month (beck, 1993). The cut-off score of the Beck Depression Inventory ranges
from 22-35.

Quantitative Interpretation. The quantitative interpretation of this scale is as follow.

Low Moderate Severe Extremely Severe

Depression 0-20 21-30 31-40 40+

Qualitative Interpretation. The client’s score for depression is 42. It means that the client
is suffering from extremely severe depression.

Generalized Anxiety Disorder. The General Anxiety Disorder 7-item scale

(GAD-7) is one of the tools used to screen for anxiety or to measure its severity (Spitzer er al.,
2006). The cut-off score of the Beck Depression Inventory ranges from 8.

Quantitative Interpretation. The quantitative interpretation of this scale is as follow.

Low Mild Moderate Severe

GAD 0-4 5-9 10-14 15+
 Qualitative Interpretation. The client’s score for anxiety is 17. It means that the client is
suffering from extremely severe anxiety.

Case Formulation

The case formulation was done after the assessment, according to the Bio-Psycho-Social
Model in which included factors were predisposing, precipitating, perpetuating and protective.

Predisposing factors are those that put an individual at risk of developing a problem.
These may include genetics, life events, or temperament (Racin et al., 2016). According to the
given history, the client’s predisposing factor were low socioeconomic status and divorce in
client’s case. Low socioeconomic status and prior negative life events are documented risk
factors for antenatal anxiety and depression (Verbeek et al., 2019).

Precipitating factors refer to a specific event or trigger to the onset of the current problem
(Racin et al., 2016). Separation from children and conflicting second marriage were the
precipitating factor of the client. The five major consequences of marital conflict identified were
stress, feeling of depression and grief, worry about what others say beyond the disturbance with
their own spouses, and feeling of despair and hopelessness (Tasew, 2021).

Perpetuating factors also known as maintaining factors are those that maintain the
problem once it has become established (Racin et al., 2016). The factors that maintain the client’s
problem are improper treatment and head injury. Uncertainties exist about the rates, predictors,
and outcomes of major depressive disorder (MDD) among individuals with traumatic brain
injury (Bombardier et al., 2010).

The protective factors are the strengths of the individual or reduce the severity of
problems and promote healthy and adaptive functioning (Racin et al., 2016). The protective
factor involved good insight into her health. A good perception of the disease depends on its
severity and strong feelings of a good outcome (Al-Khathami et al., 2017).
Case Conceptualization
Presenting Complaints

• Anxiety
• Insomnia
• Inability to do work
• Worry
• Restlessness
• Loneliness

Assessment
Informal Assessment
• Behavioural Observation
• Clinical Interview
• MSE
• Subjective Rating Scale
Formal Assessment
• DSM -5TR Checklist
• DASS
• BDI
• GAD-7

Precipitating Factors Predisposing Factors Perpetuating Factors

• Low- • Head Injury
• Separation from
\
\
\
\
\
\
\
\
\
\
\

Children Socioeconomic • Improper Treatment

• Conflicting 2nd Status
marriage
• Divorce
 Protective Factors

• Client’s Insight

Proposed Management Plan

• Rapport Building
• Psychoeducation
• Relaxation Technique
Diagnosis • Cognitive Behavioural Therapy
• Emotional Regulation Technique
According to DSM-V-TR client falling under the criteria or might be fulfilling the
symptoms of Generalized Anxiety Disorder (F41.1), Severe with comorbid Persistent Depressive
Disorder (F43.1), Severe.

Client’s Prognosis

In the client’s case, the prognosis or chances of recovery were low but it can be
influenced by various factors, some of which are favourable, while others are unfavourable.

Favorable Factors

• Social Support including her husband's and children’s support

• Strong insight into her health can be the strong favorable point

• Proper treatment and take care of herself

• Strong spiritual beliefs can take her to recovery

• Strong socialization with her neighbors and friends can cause positive impacts

Unfavourable Factors

• If the treatment is still discontinued this time, causes the condition to get worse
• Old age is more prone to diseases and may cause severity of the problem
Intervention Strategies

Short term Goals

• To Establish a strong therapeutic relationship with the child

• To manage stress
• Encourage her to take part in hobbies gradually
• Help the client to improve her sleeping schedule
• Establish a trusting and comfortable therapeutic relationship with the child to encourage
open communication
• Teach relaxation techniques and coping strategies to help the child manage anxiety
• Educate the client about anxiety, and the effects of these conditions, providing him with
tools and knowledge to address these challenges

Long term Goals

• Continuation of short-term goals.

• Change the client’s negative thoughts to positive ones
• Proper follow-up sessions with the client
• To follow complete treatment plan
• Collaborate with the client’s family to increase their understanding of anxiety and
depression, ensuring they provide necessary support

Proposed Management plan

A proposed management plan designed to help the client to help her with her
psychological well-being and support. Rapport Building and Psychoeducation are the key
factors at initial point steps of management plan.

Rapport building

Rapport refers to a harmonious relationship between the patient and the healthcare
profession which is based on cooperation and respect. A good rapport with the client is said to
improve the patient’s therapeutic results, happiness, satisfaction, and compliance with treatment
(Butt,2021). The client was expressive about her thoughts and feelings. Overall, proper sessions
were conducted and the client was responsive to each question asked in clinical interview and
built a good professional bond with trainee clinical psychologist.

Psychoeducation

Psychoeducation is an intervention involves interaction between the information provider

and the mentally ill person or his/her caregiver (Lincoln & Wilhelm, 2007). Psychoeducation
would help the client to show compliant behavior regarding the treatment of any psychological
issue. Psychoeducation could provide awareness to the client regarding her issue and which
practices can help in overcoming those issues and problems. Overall, the client was psycho-
educated about her condition its psychological impacts on client’s life.

Cognitive Behavioral Therapy

Cognitive behavioral therapy combines both cognitive and behavioral therapies to deal
with the current problems of the client. CBT is a directive form of psychotherapy that assists
patients in questioning their troubling ideas and altering the behaviors that are connected to them
(Beck, 1960). CBT was used with the client to help her realize her feelings and thoughts which
can be harmful and how we can modify them, and made us positive and in a happy mood and can
help in recover her skin disease soon.

Relaxation Techniques
The use of therapeutic relaxation techniques has been developed to benefit people by
lowering stress and anxiety Guided imagery, progressive muscle relaxation, deep breathing, and
other techniques for relaxation are some of them (Norelli et al., 2022). To treat stress, anxiety,
sadness, and pain, these techniques could be expanded to include a variety of contexts. The client
was taught Deep breathing and guided imagery to manage stress and anxiety.
Emotional Regulation

Emotional regulation is the ability to recognize, manage, and respond to your emotions.
When you don’t know how to regulate emotions, these can get a hold of you and impact the way
you relate to yourself, others, and the world in general. Emotional dysregulation refers to
experiencing difficulty when trying to diffuse or manage strong emotions, particularly those
considered negative like anger, frustration, and jealousy. When emotions impact your overall
quality of life, relationships, or performance at work or school, you may want to explore healthy
ways to cope ((Lebow, 2022). Emotional regulation involves noticing what you feel, naming
what you feel, and accepting the emotions. Emotions happen fast and we are suddenly clench-
jawed and furious. So, the number one skill in regulating difficult emotions, the gift we can give
ourselves, is to pause. Take a breath. Slow down the moment between trigger and response. The
client was taught such skills to regulate her emotions.

Limitations
• Unavailability of a psychiatric ward
• Time to gather information was very limited as proper time was not given for gathering
more data.
• The session was not much comfortable while the sessions due to the presence of other
patients.
Recommendations
• There should be a proper psychiatric ward
• Time period for assessment should be extended.
• Information should be gathered from significant others.
• Assessment should be carried out in an open environment which should be free of
distractions.
 Session Report

The session was carried out in the OPD of the Allama Iqbal Hospital. The client was
assessed both formally and informally. The client’s history was taken through a clinical interview
during which the client was observed for her verbal and non-verbal behaviour. According to the
presenting complaints of the client, Beck's Depression inventory, GAD-7, and Depression
Anxiety Stress Scale was also administered for a better evaluation of the client’s reported
symptoms. The session ended with an assessment of the client’s condition. The session was
ended after rapport building and psycho-educating the client about her condition and telling her
ways to improve her psychological wellbeing. The overall session was ended on a good note.
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